Victoria House Application
VICTORIAN PROPERTIES LLC2009. AZ, USA.
Victoria House Application
Part 1 of 2. Prospective Resident Details, Application/Resident
Status Update.
Robert E. Widing IIIPart 1 of 2
Drafted on 10/01/08Revised on 05/17/09Revised on 06/26/09Revised
on 11/19/09
This document provides no guarantees, commitments or
responsibilities, remains the property of, and is subject to
approval by; shareholding member/s, company officer/s and/or the
Authorized /Responsible Agent/Representative of Victorian
Properties LLC to act on behalf of the company. Authorization/s
and/or appointments to act on behalf of the company and/or its
subsidiary; Victoria House in the Commonwealth of Pennsylvania are
subject to the LLC' Operational Agreements and the laws of its
Jurisdiction. Agreement/s are; subject to Approval, non-binding,
sever-able and may change until consideration is exchanged.
Victorian Properties LLC is an Arizona based Limited Liability
Company and reserves all rights afforded under Federal, State,
Commonwealth and Provincial Authorities including but not limited
to the right/s of; Limited Liability, Civil and/or Criminal
Restitution, Lien and Rights given under applicable Landlord Tenant
Acts or Laws in/lieu of a Governing Act via; Statute, Tort,
Judgment or other Legal Remedies. Agreements with Victorian
Properties LLC are subject to the Laws of its State of
Incorporation and/or operation. Agreements under the LLC'
stamp/seal supersede that of any regional law/s with the exception
of Applicable Federal Statutes that may be proven via; Hearing,
Trial or Judgement set by Governing Courts of; District
(Magisterial), County, District (Appeals Circuit), State and/or the
Supreme Court of the United States of America in Constitutional
and/or Amendments therein, to Uphold the Law of the Land.
DBA VICTORIA HOUSE 1.a) Current Living Arrangements &
Related
Full Name:
____________________________________________________________________Current
Residents: Tick NO for the next 2 Questions.Are you coming from a
Rehabilitation or Treatment center?YES_____NO_____
Are you coming from a Halfway/Group House or
Similar?YES_____NO_____If you answered YES to either question,
please write down the name of center, institute or house including
the type of service they provide, ie; drug/alcohol rehabilitation,
counseling (types) etc.* If NO, skip to 1.b) Address and write your
current mailing address or primary residency.Current AND
Prospective Residents: If you have a TCM Please use as your
Reference.Facility (Examples; Salvation Army Rehabilitation Center,
Snow House or Maria House Projects):
Facility: _____________________________________ Length of Stay:
____________________
Purpose of Stay:
________________________________________________________________
Discharge Date: ______/______/______ OR Lease/Contract End Date:
______/_______/______Reference (Counselor, Psychiatrist, Employer,
House Manager, Center Coordinator, Therapist etc.)
Reference Name: _________________________________ Position:
______________________
Work# __________________ Mobile# ___________________ Other#
____________________
1.b) Current Address and Contact Information Address:
____________________________________________________________________
____________________________________________________________________
Phone: H: ____________________ M: _____________________W:
___________________
Other: _______________E-mail:
__________________________________________N/O/K: Name:
___________________________________ Relation:
____________________
Phone: Home: _________________________ Mobile:
_______________________________
NOTE: Next of Kin MUST BE CONTACTABLE. Write 2 CURRENT phone
numbers
2.a) Criminal History Information (Current Residents: List any
Changes if any)
Please answer HONESTLY. Falsifying information may have serious
legal consequences.
1. Do you have a criminal history?YES______NO______
2. If YES, is it a Felony?YES______ NO______
3. Are you on Probation or Parole?YES______ Fill (a1)NO_____
Skip (a1)
(a1) If YES to last question, please provide: Type of paper are
you on? P/O or Agents Name, Contact Number w/ext? Duration? ANY and
ALL Conditions of Parole?Current Residents: Treat as new
application noting everything Before AND During
stay:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(a2) If YES to either questions, please BRIEFLY, describe the
charge/s. Do not put down any unresolved or non-disclosed
information that may put you at risk of further prosecution. Please
write down only what you have been convicted of, have satisfied
judicial punishment for and are absolved of or still involved in
the reparations process; State Parole, County Probation etc. *If
this section is not applicable, please write a large N/A.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2.b) Outstanding Legal or Related Issues
(b1)If you have any outstanding legal issues such as court
appearances, mandatory drug or alcohol tests, probation officer
visits, mandatory counseling etc. Please write them down. This is
not to be intrusive but Victoria House Management must know if
there are to be unexpected visits or issues from legal or Law
Enforcement Authorities.*If this section is not applicable, please
write a large N/A.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3) Employment and Financial Viability.
This section is to establish how you are planning to support
yourself. Please only fill out what is applicable to you. You will
not be judged, marked or attain any advantage in this section as
its only aim is to establish if you will be able to afford to live
at Victoria House. For example, if you do not plan on working due
to disability, or are unemployed and family are going to help pay
rent until employment or studies are started, list it.
Employment or EmployableAre you working or have a confirmed
future job?YES_________ NO_________
If YES, Please list your job and or upcoming job, including the
name of the business, location details and the contact number of
the business and/or a supervisor/manager.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If NO, are you going to be looking for work?YES_________
NO_________
If YES or NO, briefly explain how you are going to be able
manage financial obligations on an ongoing and sustainable basis.
Also, If NO, write how you are going to better
self/community?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Government sponsored Disability PaymentsAre you currently on a
government subsidy or disability? YES_________ NO_________
If YES, will you be on this payment for 3 months or more?
YES_________ NO_________
What is the name of this benefit/s?
_________________________________________________
CASH ($) and/or FOOD STAMP (FS$) Entitlements: $______._______pm
FS$____________
If NO, will you be able to find alternate income sources?
YES_________ NO_________
DO YOU BELIEVE THAT YOU WILL BE ABLE TO MEET THE FINANCIAL
OBLIGATIONS NEEDED TO LIVE AT VICTORIA HOUSE?
YES________NO________
4.a) Alcohol and Drug Information
Victoria House is a recovery house for those recovering from
drug/alcohol affliction. This section assumes a lot and therefore
it is up to the individual as to how in depth he answers.
Are you primarily an:
________ Alcoholic
________Drug Addict
________Duel Diagnosed
________All of the above
What is your Drug of Choice (If primarily Alcoholic, put
Alcohol)? _______________________
Current Residents: Treat as a new application. Note any
Relapse/Incident/Hospitalization etc.What other drug or drugs (if
any) have you had a problem/s with (including prescription
meds)?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you completed or been in a 28+ day inpatient OR outpatient
program? YES____ NO_____
Do you have OR require a continuation of care or follow a
treatment plan? YES ____ NO ____
4.b) Other Related InformationCurrent Residents: Include ANY
Changes:How long have you been clean from your primary DOC?
_______________________________
How long have you been completely clean of all drugs/alcohol
including prescription medication that is/was; not prescribed, not
taken as prescribed, abused and/or not under medical supervision
with regular consultations from a Doctor or Psychiatrist for
psychotropic/scheduled medications? ANDHow long you have been clean
of your Drug of Choice as well as any other drugs that you should
not have taken? How long have you been a "responsible" clean person
in recovery? And briefly detail your last
relapse/hospitalization/arrest; informing; what drug/s, type/s of
alcohol, why etc.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5.a) Voluntary Medical Disclosure
This section like all others is kept with complete
confidentiality. The purpose of this section is to help safeguard
you as an individual from theft, false accusations and any other
mishaps regarding prescription medication. Furthermore this will
help to provide understanding of any conditions you may have.
NOTHING in this section will influence your decision on admittance.
Victoria House allows admittance based on the character of the
individual NOT medical conditions.
This question is COMPLETELY optionalDo you have any medical
conditions that you wish to notify Management about should you so
provisions may be made to save you embarrassment, harassment or
unnecessary bad feelings? This applies for any condition and
Management can provide; extra privacy, extra sheets, lifts for
preventative treatments of chronic life threatening conditions (may
require documentation), additional disinfectants/detergents, better
security, more separated food storage options etc.
YES_______NO_______
5.b) Mandatory Medical Information
Are you on any prescription medications?YES_______NO________
If yes, Please list the medications you are taking. Please note:
You are responsible for your own medications. Management will not
hold, dispense or place in security any of your medications. The
security and management of your medications are your own
responsibility; however, you MUST detail what you are on, keep your
medications in labeled prescription containers, take as prescribed
and notify Management of any changes including the collection of
medication from a new or different doctor than that of your other
medications.Please understand, this is for your protection, in the
case of stolen/missing meds, the usage of non prescribed
medications or the possession of non prescribed medications may
result in your contract termination. In some cases police
involvement may be necessary. When multiple parties are involved,
whoever is most upfront and honest typically gets the benefit of
doubt. Medication/s: Current Residents: List Meds W/Dosage. Write
Down ANY Changes in the Last 3
Months:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are any of these medications Scheduled (schedule 1, 2, 3, 4 or
5) or listed under the Federal Controlled Substance Act (Body
corporate will terminate residency if not informed)?
Yes_______NO_______
If yes, list the medication/s in the above section. A YES answer
is OK if DR. PRESCRIBED and monitored. If so its recommended you
purchase a lock box for security (can easily be arranged).
6) Individual Considerations, Conditions, issues or
Agreements
PLEASE COMPLETE Q1 and Q2 WITHOUT HOUSE MANAGER PRESENT
Q1) Applicant and/or Resident have and agreed/disagreed to
address the following (Any Issues):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Q2) I have the following Concerns and/or feel these Suggestions
or Changes are worth mentioning:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Q3) This brought us both to the following conclusion/s: COMPLETE
WITH
MANAGER:________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
COMPLETED:APPLICANT (X) __________________________________ DATE
______/______/______MANAGER (X)
__________________________________DATE _____/______/_______
END PART 1STAMP OR SEAL AUTHORIZED REPRESENTATIVE (PA) ROBERT E.
WIDING IIIINTERNAL USECOMP: _______/______/______
APP/DEC__________________ DT______/_______/_______ASST:
______/_______/______ P2RA _____/______/_____ P2-SP Y____ N ____
C_____VICTORIAN PROPERTIES LLC2009. All Rights Reserved.APPLICATION
INFORMATIONPART 1 of 2RESIDENT UPDATES/sDBAVICTORIA HOUSE. 1156 W.
11TH STREET. ERIE, PA, 16502. (814) 528-5600 or (623)
313-4391APPLICATION INFORMATIONPART 1 of 2RESIDENT
UPDATES/sDBAVICTORIA HOUSE. 1156 W. 11TH STREET. ERIE, PA, 16502.
(814) 528-5600 or (623) 313-4391
APPLICATION INFORMATIONPART 1 of 2RESIDENT UPDATES/sDBAVICTORIA
HOUSE. 1156 W. 11TH STREET. ERIE, PA, 16502. (814) 528-5600 or
(623) 313-4391
